Lower back pain within an individual’s context

JP Caneiro outlines the case study of a patient suffering with chronic lower back pain to explore the challenge of integrating contemporary knowledge in clinical practice in an edition of the Australian Physiotherapy Association’s magazine InTouch. JP Caneiro is a Specialist Sports Physiotherapist (as awarded by the Australian College of Physiotherapists in 2013) who consults at Body Logic in Perth and lectures in the Clinical Masters in Physiotherapy at Curtin University. He is undertaking a PhD investigating the process of change in people with LBP and high fear undergoing a personalised CFT intervention.


‘When the doctor asked me how I had injured my back, I said: “No idea—it just started getting sore.” He said I needed some time off work so the back could heal and I could learn how to lift properly with the physio” , JM, manual worker with chronic back pain.

Despite the growth in research data that challenges the beliefs which drive current healthcare practice, there is still a gap between evidence and clinical practice (O’Sullivan et al 2016). Professional boundaries are currently being challenged when managing a person with persistent pain. To make sense of pain at an individual level, current knowledge requires healthcare practitioners to broaden their scope of practice to look and act beyond the physical dimension (Moseley and Butler 2015, O’Sullivan 2012, Wand et al 2011).

However, recent work has highlighted that the physical dimension is still the one of preference by practitioners. Specifically, physiotherapists find it difficult to identify and integrate non-physical factors effectively in clinical practice (Singla et al 2015, Synnott et al 2015). Aiming to bridge this evidence-practice gap, the following case illustrates the integration of contemporary knowledge into clinical practice, in which pain is considered within the individual’s context.


A common story of pain

JM is a 38-year-old male manual worker with eight months’ history of low back pain, which developed insidiously. Despite the absence of clinical signs indicative of red flags, trauma or neurological deficits JM was referred for a scan. The scans results showed disc bulges and degenerative changes at the two lower lumbar levels, with no nerve compression. JM was told the scans were ‘not too bad for his age’ and that he just needed some time to ‘heal’. Initial management included a couple of weeks off work and physiotherapy.

After six months of manual therapy, postural re-education, activity modification and several weeks on/off work, JM was on light duties and not feeling better. In fact, he was worse. He lost confidence in his back and in his ability to return to full-time work; he was fearful that bending his back could lead to further injury; he was concerned about not being able to provide for his family; he was not sleeping well, worried about the future of his back, and frustrated that he was now doing the right things but was still not able to do what he needs (full work duties) and likes (exercise).

This story highlights the influence of an outdated, yet highly-used, pathology model of reasoning’, in which pain is attributed to injury and where the body is vulnerable to tissue damage under certain physical demands. Strategies such as time off work and posture-modification were used to allow adequate ‘healing’ and protection from ‘re-injury’. Such reasoning may be interpreted as adequate in the presence of an actual injury, where trauma and tissue damage occurred. However, this was not the case here.


Identifying contributing factors to pain experience

To look at this person’s story from a more contemporary perspective, the interview should include questions that are broader than, ‘How did you injure/hurt your back?’, which uses language that assumes tissue damage has occurred, priming the patient to answer within an injury framework. In contrast, asking, ‘What else was happening in your life around the time that your back got sore?’ revealed significant levels of contextual stress for more than six months prior to his back pain. JM and his wife were trying to have a second child through IVF, which was causing emotional and financial distress. As a consequence, JM picked up a few more hours at work, which in turn reduced his time for exercise and impacted on the quantity of his sleep. As a couple, they were also involved in community volunteer commitments on the weekends and, lately, a couple of evenings a week. Although he enjoyed it, these commitments were taking up a lot of his spare time. As part of a thorough interview, this style of questioning facilitated a conversation that was open, non-judgemental and reflective in nature, providing an opportunity for the patient to disclose a series of factors known to influence a person’s pain experience.

Questioning about the cause of his pain revealed that he believed it to be related to the damage to his back, which was caused by incorrect posture (not keeping it straight) while bending and lifting. JM reported high fear and pain anticipation when bending to pick a pen off the floor. JM moved slowly, guarded and squatted to avoided flexing his spine. He reported avoiding bending as much as possible due to fear of causing further damage and risking not being able to continue work. Guided bending, without bracing and allowing the spine to flex revealed higher fear and pain anticipation and, to his surprise, reduced his pain experience. This behavioural experiment provided an opportunity to challenge his beliefs and created a new positive experience.

Guided by a multidimensional clinical reasoning framework (O’Sullivan 2015, Vibe Fersum et al 2013) the following key contributing factors were identified from the interview and examination:

• emotional familial distress
• fear of being out of work and not being able to provide for family
• fear that work activities (bending and lifting) caused injury to back.

• financial distress
• working extra hours
• busy with volunteer work.

• physically-demanding job
• protective bending and lifting (moving slowly, squatting and bracing).

• exercising less
• sleeping less.

The interplay of these factors may provide sufficient input to sensitise the nervous system, creating an environment for the expression of neuro-immune-endocrine protective responses such as pain (O’Sullivan 2016, Moseley and Butler 2015). Understanding this perspective has a fundamental impact on how to manage this person.


How to put it all together?

The identified modifiable factors were targeted to promote change in the system towards the person’s needs and goals. In this case, the management plan was to:

Facilitate better understanding of the pain problem
• reconceptualise pain by dispelling the myth that his pain was related to an injury. Rather, pain emerged as a consequence of an interplay of underlying stress (familial, financial) and lifestyle changes (inactivity, poor sleep). This, coupled with fear of causing further injury and the adoption of protective behaviours (avoidance of bending, bracing), led to pain persistence and loss of function
• explain that physical factors were one of many factors which could influence his pain experience; and that the evidence suggests the way you bend is not related to risk of pain (Wai et al 2010) and how far you bend is not associated with more pain (Villumsen et al 2015)
• de-threaten his MRI scans—explaining that close to 68 per cent of pain-free people at this age present with disc degeneration and 50 per cent present with disc bulges (Brinjikji et al 2015); and these changes are not predictive of future pain (Jarvik et al 2005).

Facilitate normal (non-protective) movement
• guided movement re-training to abolish protective behaviour. The key message was to stop protecting his back and to return to bending and lifting as he used to before (not worrying about posture)
• resume normal work duties (manual work) without the thought that bending and lifting are dangerous. Exposure to the feared task in a controlled manner can promote confidence and conditioning.

Lifestyle advice
• suggested to minimise volunteer commitments (temporarily), allowing time for physical activity
• sleep hygiene strategies to resume normal routine.

After two months of this individualised approach, JM was back working his full duties most days of the week, exercising, sleeping better and reporting a significant reduction in fear of bending. He reported that the reconceptualisation of pain was central to his ability to change, and that practising a new strategy allowed him to resume work confidently.


Bridging the evidence-practice gap – an obstacle or an opportunity?

In light of uninspiring outcomes of intervention trials testing traditional healthcare practice that question current practice beliefs, and the feeling of inadequacy in integrating contemporary evidence in clinical practice reported by physiotherapists, this challenging scenario can be seen by many as an obstacle, a moment of crisis in our profession. My view, and that of others, is that this is an opportunity for development of new skills that make us better equipped to deal with the complex problem of pain (Caneiro et al 2016, O’Sullivan et al 2016).

Physiotherapists that have been trained to broaden their skill set towards a multidimensional approach to pain report positive changes to their clinical practice (Synnott et al 2016, Nielsen et al 2014). In order to accept a more contemporary approach in clinical practice, physiotherapists will need a flexible mindset to adapt traditional professional beliefs


Email negeditor@physiotherapy.asn.au for references.

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